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Ideas and Opinions |

What Is Our Plan for Acute Unscheduled Care?

Keith E. Kocher, MD, MPH; and Brent R. Asplin, MD, MPH
[+] Article, Author, and Disclosure Information

From University of Michigan, Ann Arbor, Michigan, and Fairview Health Services, Minneapolis, Minnesota.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-3036.

Requests for Single Reprints: Keith E. Kocher, MD, MPH, University of Michigan, Department of Emergency Medicine, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 152S, Ann Arbor, MI 48109-2800; e-mail, kkocher@umich.edu.

Current Author Addresses: Dr. Kocher: University of Michigan, Department of Emergency Medicine, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 152S, Ann Arbor, MI 48109-2800.

Dr. Asplin: Fairview Health Services, 2450 Riverside Avenue, Corporate Office Building, Minneapolis, MN 55454.

Author Contributions: Conception and design: K.E. Kocher, B.R. Asplin.

Analysis and interpretation of the data: K.E. Kocher.

Drafting of the article: K.E. Kocher, B.R. Asplin.

Critical revision of the article for important intellectual content: K.E. Kocher, B.R. Asplin.

Final approval of the article: K.E. Kocher, B.R. Asplin.

Collection and assembly of data: K.E. Kocher.

Ann Intern Med. 2013;158(12):907-909. doi:10.7326/0003-4819-158-12-201306180-00008
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The fundamental question of where patients with acute care needs should go for unscheduled care is left inadequately answered in the debate over health care reform. This commentary discusses the burden of and an ideal system for acute unscheduled care.

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Comparison of U.S. health system outpatient visits, by setting and primary care specialty.

All data are from 2007 except for acute care visits, which are averaged over 2001–2004. Numbers in parentheses are references.

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Acute unscheduled care
Posted on June 19, 2013
Michael N. Dohn MD MSc, Anita L. Dohn MD MSc
Clínica Episcopal Esperanza y Caridad, San Pedro de Macorís, Dominican Republic
Conflict of Interest: None Declared

To the editor: We read with interest the observations of Kocher and Asplin (1) regarding acute unscheduled care. We reside outside the United States and recently confronted a decision about acute health care when a fall resulted in a wrist injury for one of us (ALD) while visiting in the USA. Rather than seeking emergency care for what was almost certainly a fracture, we instead chose to splint and cool the wrist (about $35 for the wrist splint and cold packs at a pharmacy) until we returned to the Dominican Republic several days later. The AP and lateral radiographs of the wrist ($14 retail cost in the Dominican Republic) confirmed fractures of the heads of the radius and ulna. We read the films ourselves (along with every physician and nursing colleague present at the time) and saved the cost of an official reading (about $5). Without a primary care physician or medical home setting available to us in the USA, we had faced the inconvenience and expense of an emergency room visit. Our interest was “less about the provider and more about timely access” (1, p 907), as well as the out-of-pocket cost and the possible impact on our future health insurance premiums. As physicians, we consider ourselves knowledgeable health care consumers and also realize that we have more options available to us than the average patient. However, looking at the “challenge of acute unscheduled care” (1, p 907) from the patient’s perspective, we opted for self-care and leaving the country.

1. Kocher KE, Asplin BR. What is our plan for acute unscheduled care [Ideas and Opinions]. Ann Int Med. 2013;158(12):907-9.

What Is Our Plan for Acute Unscheduled Care in England?
Posted on July 8, 2013
Thomas E. Cowling, MPH, Matthew J. Harris, MBBS, DPhil, Azeem Majeed, MD
Imperial College London
Conflict of Interest: None Declared

Kocher and Asplin’s discussion of acute unscheduled care in the U.S. (1) resembles the debate on the same topic in England, where the National Health Service (NHS) is conducting a comprehensive review of unscheduled care services (2).

In England, general practice offices, staffed by primary care physicians, and hospital emergency departments (EDs) form the two “silos of acute care delivery” (1). Approximately 9% of patients who are unable to obtain a convenient appointment at their general practice office subsequently visit an ED (3). Consequently, recent national policies have attempted to improve access to general practice, using financial incentives, to reduce demand for acute unscheduled care at EDs. A national, observational analysis suggests that more timely access to general practice is associated with lower rates of ED visits in which the patient is self-referred and discharged (4). Therefore, the objective of these policies may be worth pursuing further in England, and possibly in the U.S. as suggested by Kocher and Asplin (1).

The NHS has also experimented with the provision of acute unscheduled care in alternative settings, such as “walk-in centres” and “urgent care centres”. These services are designed for patients with low-acuity needs, are typically staffed by primary care physicians and nurses, and may have access to diagnostic facilities. Some of these services are co-located with EDs to prevent patients without the clinical need for investigation or treatment in an ED from contributing to ED workload (5). A potential unintended consequence of expanding alternative care settings is that the “question of where patients with acute care needs should go for unscheduled care” (1) becomes more confusing for patients themselves, which has been observed in the NHS (2). Additional demand for unscheduled care could also be generated from an increase in the supply of acute unscheduled care services, presenting another undesired result of this policy.



1. Kocher KE, Asplin BR. What is our plan for acute unscheduled care? Ann Intern Med. 2013;158:907-9.

2. NHS England. High quality care for all, now and for future generations: transforming urgent and emergency care services in England. 2013. Accessed at www.england.nhs.uk/uec-england/ on 28 June 2013.

3. Ipsos MORI. The GP Patient Survey Overall Practice Report (July 2012 - March 2013). 2013. Accessed at www.gp-patient.co.uk/results/latest_weighted/practice/ on 28 June 2013.

4. Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A, et al. Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study. PLoS ONE. 2013;8. doi:10.1371/journal.pone.0066699.

5. Gnani S, Ramzan F, Ladbrooke T, Millington H, Islam S, Car J, et al. Evaluation of a general practitioner-led urgent care centre in an urban setting: description of service model and plan of analysis. JRSM Short Reports. 2013;4. doi:10.1177/2042533313486263.

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